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Bone Grafts / Bone Graft Substitutes

 

Bone Graft Substitutes

Allosoure Allofuse
Biomet ProOsteon
Biomet InterGro DBM
Biomet BonePlast
Exactech Opteform
Exactech Optefil
Exactech Optecure
Exactech OpteMx
Isotis AccellDBM
Isotis Accell Total DBM
Isotis Accell Conexus
Lifenet Optimum DBM
Lifenet IC Graft
Lifenet Cellect DBM
Lifenet OraGraft
Medtronic Infuse
Medtronic Granules
Medtronic Matrix
Medtronic Putty
Medtronic Osteofil DBM
Orthofix Osteomax
Osteotech Grafton
Stryker OP-1 implant
Stryker OP-I putty
Stryker Calstrux
Stryker Hydroset
Synthes DBX
Synthes Norian
Synthes Chronos
Wright Osteoset
Wright MIIG X3
Wright Cellplex
Wright Allomatrix
Wright Ignite
Zimmer CopiOS

Bone healing stages Cancellous Chips
Positive Bone Healing Factors Corticocancellous bone segments
Negative Bone Healing Factors Autograft
Platelet Concentrates / Autologous Growth Factor (AGF) Growth and Differentiation Factor 5
Calcium Phosphate

Hydroxyapatite

Calcium sulfate Tricalcium Phosphate
Demineralized Bone Matrix (DBM)

Bone Morphogenetic Proteins (BMPs)

Bone Marrow Aspirate  

Bone healing stages: Impact > Induction > Inflammation > Soft callus(5-21days) > Hard callus > Remodeling.

Vascular Phases of Bone repair:

  • Phase I: 0-1wk: reduction in blood flow
  • Phase II: 1-4 weeks increased blood flow
  • Phase III: 5-8 weeks returns normal

Positive Bone Healing Factors

  • High vascular fracture areas
  • Increased bone surface area
  • Mechanical stability
  • Mechanical loading
  • Bone Growth Factors (BMP 2,3,6,7,9)

Negative Bone Healing Factors

  • Smoking (nicotine, and decreased oxygenation)
  • Diabetes
  • Radiation
  • Tumors
  • Mechanical instability
  • Infection
  • Corticosterioids
  • Chemotherapy
  • Malnutrition
  • Metabolic bone disease
  • NSAIDs
  • HIV

Cancellous Chips

  • 5- to 7-mm freeze-dried cancellous chips
  • Limited structural support; osteoconductive and limited osteoinductive

Corticocancellous bone segments

  • May be cut to shape/size/fill segmental defects
  • High structural support, osteoinductive
  • Disease potential; immunogenicity; slow incorporation

Autograft: see Myeroff C, Archdeacon M: Autogenous bone graft: Do- nor sites and techniques. J Bone Joint Surg Am 2011; 93(23):2227-2236

Distal Tibia

Iliac Crest Autograft

  • Gold standard
  • Osteoconductive, osteogenic. Minimal active BMPs.
  • Complications: acute/chronic donor site pain, infection, fracture, hematoma (Arrington ED, CORR 1996;329:300)
  • Ebraheim NA, JAAOS 2001;9:210

Proximal Tibia

Allograft

Platelet Concentrates / Autologous Growth Factor (AGF)

  • Rich in platelet-derive growth factor, TGF-B,
  • Has not been shown to be beneficial in spinal fusion (Weiner BK, Spine 2003;28:1968)

Growth and Differentiation Factor 5

  • Synonms: MP-52, LAP-4, CDMP-1, BMP-14, Radotermin, Healos/rhGDF-5
  • 100% fusion rate in rabbits (Magit DP, Spine 2006:31:2180).
  • Further human research needed

Ultrasound

Calcium Phosphate

  • Injectable through minimal incision
  • High compressive strength
  • Not osteoconductive or inductive
  • Slow reabsorbtion, limited shear or tensile strength

Calcium sulfate

  • Pellets, paste, putty
  • Injectable through minimal incision; may be combined with antibiotics
  • Minimal structural support, water-soluble, rapid resorption

Hydroxyapatite

  • Slowly degradable ceramic
  • Animal studies demonstrate increased fixation strength, no clear clinic advantage.
  • Can be shaped to fill defect
  • Slow resorption

Tricalcium Phosphate

  • Synonyms: beta-tricalcium phosphate
  • Osteoconductive. Osteogenic and inductive when mixed with marrow aspirate.
  • Minimal to no structural support, variable rapid resorption rates
  • Trade names: Vitoss, Orthovita, Malvern, PA

Demineralized Bone Matrix (DBM)

Bone Morphogenetic Proteins (BMPs)

  • Low molecular weight noncollagenous glycoproteins; part of TGF-beta superfamily.
  • rhBMP-2 (Infuse-Metronic) has shown clinical utility in spinal fusion (Glassman SD, Spine 2005;30:1694) and tibial fractures (Swiontkowski MF, JBJS 2006;88A:1258).
  • BMP-7 (OP-1-Stryker): has shown clinical utlity in spinal fusion (Vaccaro AR, Spine 2005;30:2709) and tibial nonunions (Friedlaender AR, JBJS 2001;83A(suppl 1):s151).
  • recombinant BMPs have been shown to increase new cancer risk in lumbar spinal arthrodesis patients at 40mg rhBMP-2/CRM. (Carragee EJ, JBJS 2013:95:1537-45)

Bone Marrow Aspirate

  • Bone marrow is aspirated from both anterior iliac crests, concentrated on a cell separator, and then injected percutaneously.
  • 88% helaing rate in atrophic tibial nonuions. (Hernigjou P, JBJS 2005;87A:1430).

 

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